As physicians, nurses, and practice managers continue to adapt to an ever-changing landscape, healthcare disruptions affecting providers, payers, and patients have become the status quo. During a recent oncology conference, thought-leader panelists advised participants to expect the unexpected, not just in oncology, but in the medical system as a whole.
Oncologists and Primary Care
The relationship between primary care and specialists is emerging as a key point of interest, as well as that between hospitals and payers, notes Roy A. Beveridge, MD, senior vice president and chief medical officer, Humana. Dr Beveridge estimates that the payer world and the provider world are getting closer. Risk sharing will fundamentally change how all physicians do things over the next 5 years.
Fragmentation of care is another area in which changes are being made that oncologists will have to deal with, he notes. As the move continues toward accountable care organizations (ACOs) or paying for quality, the fact that no one individual is really responsible for the entire patient is going to cause problems. Norma J. Ferdinand, MSN, RN, senior vice president for quality and performance improvement, and chief quality officer, Lancaster General Health, agrees.
“We are now in a position where our primary health physicians are becoming eligible for the total cost of care, which is something that they haven’t had access to information [about] in the past,” Ms Ferdinand said. “It is changing the whole model of how they provide care and their accountabilities for managing a panel of patients, [which] include managing the cost of care. The current system is extremely fragmented, with no one provider ruling over access and cost of care. So, making a system that is more integrated will be needed.”
Integrating all of the stakeholders in patient care may be difficult or disruptive, notes Kim Woofter, RN, OCN, chief operating officer, at Michiana Hematology Oncology, PC, in South Bend, IN. While quality is understood to be the ultimate goal, it is unclear who is ultimately responsible for care of the oncology patient, and, importantly, who will own the quality process for optimal care. Resolving this uncertainty will drive oncology care going forward. Even though a lot of time has been devoted to the changes, there is still much that is not well-understood.
Practice and Patient Disruptions
As with quality, healthcare exchanges may also change the nature of the purchase of oncology services, notes John E. Hennessy, MBA, vice president of operations, Midwest division oncology, Sarah Cannon Cancer Center. At the time people purchase insurance, they either have cancer and know they need good providers or do not and likely think they never will. Because of this, cheap insurance often beats quality of the network. This creates an imperfect buying environment, where people are making purchasing decisions that are separated from the time of actual medical need. Thus, different priorities will be at work.
“The concept that we can come out and produce the best cancer program in town may not translate to the purchaser recognizing it or wanting to buy it,” Mr Hennessy said.
Disruptions will also occur for the patient. Nancy Davenport-Ennis, founder and chairman of the board, Patient Advocate Foundation, Hampton, VA, noted the accelerated growth of the completely uninsured patient. In 2012, 38% of those her foundation worked with had no insurance at all—the highest level in the 17 years they have been compiling that statistic.
“What is disruptive for patients is the complete lack of stability in the oncology community today,” Ms Davenport-Ennis said. “We may want to enroll a person in a clinical trial, only to be told that provider is out of network. The reimbursement structure for the physicians trying to take care of our patients, and the fact we have lost 217 practices over the last 2 years, is disruptive for our patients depending on those practices for treatment.”
The changes upcoming in Medicare are another disrupter in the payment system and the delivery system. Within 8 years, 60% of the patient population will be on Medicare or Medicaid. Both are heading away from a pay-for-service to a pay-for-value model.
“The remaining folks are going to be in a disproportionally large number of exchange programs, all of which are going to be managed,” said Dr Beveridge. “What we as specialists have not understood is this giant revolution that has [already] gone on in the family practice and primary care world. Right now, these doctors are paid on their quality scores by every insurer.”
Technology Disruptive
Technology will be more and more disruptive to the oncology practice going forward.
“On the technology side, this is really going to be overwhelming,” said Al B. Benson III, MD, professor of medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. “I wonder how a general medical oncologist is going to be able to adjust to the massive changes in technology. We are now able to subset our patients based on molecular biology and other areas, which will vastly increase the knowledge base that an oncologist will need to provide care across many different cancers and subsets of patients within each disease category.”
There will be a need to tailor entire systems and hierarchies of care based on the molecular profile of the patient in front of them.
“At the [American] Society of Clinical Oncology meeting in 2013, researchers from Sarah Cannon presented on results of anti–PD-L1 treatments for patients who had failed numerous regimens,” noted Mr Hennessy. “Now, we’re having extended disease-free survival curves of multiple years, which weren’t part of the picture when we developed early versions of clinical pathways. This has turned the logic of what we thought was the last innovation on its ear.”
Payers as Partners
Another disruptive force may be the need for oncologists to put aside previous experience and look at payers as partners in the care of their patients—especially when looking at possible innovations in care.
With the rise of bundled payment systems, ACOs, and other similar modalities, establishing partnerships with payers to gain access to their information and knowledge becomes important.
“The payers have data systems that can help providers in terms of how we rank order risks in our patients,” noted Dr Beveridge. “They have data that allow rapid understanding of where your patient is within the system. This is a fundamental shift we’ve got to work through in terms of management.”
The existence of a data-rich environment is not the end of the series. The key is converting data to information that can be acted on, to highlight good ideas for general rollout, and to spotlight bad ones that need to be eliminated. It is not just collecting it, but also measuring. What are we seeing and what are we learning? Learning has to then be converted into behavior change.
“Transparency is also very important to us,” noted Mr Hennessy. “If you’ve got information about what is working or isn’t, you have to share it. That may not sound terribly innovative, but actually making this information readily available to the community executing on it, is.”
Efficiencies Pay for Things Insurance Will Not?
Getting more efficient care may also help with some of the other issues, such as how to pay for services that are not reimbursed. Times are changing and the practice of oncology will too; these constraints have led to innovations at many levels. Michiana, for instance, has developed a triage system that takes responsibility for patients in their first 48 hours after discharge. They follow up with patients to make sure they have medications and other necessary resources.
“When discharged, my office calls the patient at 24 and 48 hours to go over their medication list, competency persistence, follow-up visits, and we also have day and night nursing availability,” said Ms Woofter. “We can affect return admissions significantly by interacting with the patients. This reduces costs.”